Daniel L. Christensen

Interest and Perceptions of Student-Run Health Clinics: A Survey at the Uniformed Services University of the Health Sciences

INTRODUCTIONnMedical students are interested in maximizing clinical experiences during preclinical years; we report an exploratory survey of student and faculty interest in a student-run health clinic (SHC) at the Uniformed Services University of the Health Sciences (USU).nnnMETHODSnWe distributed via e-mail a questionnaire to explore student and faculty opinions regarding the role of a SHC at the USU.nnnRESULTSnNearly half of the students (310/669; 46%) and one in five faculty members (78/427; 18%) responded. 227 students stated the USU should have a SHC and 247 students were willing to commit time to a SHC on a weekly or monthly basis. The majority of participants believe work in a SHC would benefit various clinical attributes representative of the Accreditation Council for Graduate Medical Education residency accreditation requirements. However, most participants believe work in a SHC would benefit only students pursuing careers in primary care whereas having less benefit to surgical careers.nnnCONCLUSIONnOur survey suggests that there is sufficient student interest at the USU to explore additional clinical opportunities early in the medical school experience; we furthermore identified a subtle yet profound difference of opinions in students and faculty regarding the benefits of early clinical exposure and different specialties.

A History of Shoulder Instability in the Military: Where We Have Been and What We Have Learned

IntroductionnShoulder instability is one of the most common pathologies seen by the orthopedic sports medicine surgeon. With a uniquely young, high-demand patient population in the U.S. Military, the incidence of shoulder instability is remarkably more common than the civilian population. As such, military orthopedic surgeons and sports medicine and shoulder specialists have developed a unique understanding and experience of shoulder instability. The historical advances of shoulder instability in the military have been instrumental in understanding the epidemiology, evaluation, pathology, treatment of first-time shoulder subluxations and dislocations, operative and non-operative treatment options, arthroscopic and open stabilization methods, management of the in-season athlete, treatment of combined and circumferential labral pathology, and associated pathology.nnnMethodsnThe purpose of this article is to chronicle the experience of military orthopedic surgeons in treating shoulder instability. We discuss how this unique experience has led to a better understanding of the epidemiology and pathology of this condition and how we have adapted our clinical practice to improve patient outcomes.nnnResultsnThe historical contribution of U.S. Military orthopedics to the understanding of shoulder instability has been monumental. This article reviews the evolution of shoulder instability treatment and the understanding as it has evolved in the U.S. Military. It further elaborates on our understanding of the epidemiology of shoulder instability in the U.S. Military, with attention given to our incidence of 1.69 per 1000 person-years, approximately 20 times higher incidence than the general population. We discuss known risk factors for dislocation that contribute to this incidence, which are specific to military service. We address pathologic changes seen following a first-time instability event, including an analysis of labral injury and the role of these pathologic changes in recurrent instability. We also review our results from arthroscopic evaluation of first-time dislocations and compare the pathologic changes with those following a first-time subluxation. Evaluation of treatment outcomes is discussed, comparing operative and non-operative results as well as open and arthroscopic stabilization in the U.S. Military population and contact/collision athletes. Finally, we address how these results drive our current treatment algorithm.nnnDiscussion and ConclusionnThe physical demands of military service result in a high rate of shoulder instability relative to the general population. For years military orthopedic surgeons have sought to better understand this pathology and learn how to optimally manage it so as to reduce this heavy burden of disease. This article discusses our experience with treating shoulder instability, provides an overview of the lessons learned, and provides a historical perspective for the evolution of shoulder instability understanding in the U.S. Military.

Biceps Tenodesis and Intra-articular Decompression for Treatment of Superior Labral Tear from Anterior to Posterior and Associated Paralabral Cyst in Active Duty Military

BackgroundnTo examine the outcomes of combined biceps tenodesis and indirect, intra-articular arthroscopic paralabral cyst decompression for the treatment of active duty military patients with superior labral from anterior to posterior tears and associated paralabral cysts.nnnMethodsnRetrospective chart review of all active duty patients at our institution from 2011 to 2014 with superior labral from anterior to posterior tears and associated paralabral cysts at the spinoglenoid notch treated with biceps tenodesis and indirect arthroscopic cyst decompression. Patient charts were examined for pre- and post-operative parameters including strength, range of motion, visual analog scale pain score, American Shoulder and Elbow Surgeon Score, and Single Assessment Numeric Evaluation Score.nnnResultsnSeven patients met study criteria. All patients presented with chronic shoulder pain and decreased external rotation strength, and three patients had clinically apparent muscular atrophy. Pre- and post-operative assessment showed external rotation strength increased from a median of 4 (range 4-4) to 5 (range 4-5; p-value = 0.014), Single Assessment Numeric Evaluation increased from a median of 50 (range 0-70) to 75 (range 30-95; p-value = 0.031), American Shoulder and Elbow Surgeon increased from a median of 46.0 (range 32.0-58.0) to 66.5 (range 58.0-98.0; p-value = 0.068), and visual analog scale pain score decreased from a median of 3 (range 1-8) to 0 (range 0-5; p-value = 0.017). Median follow-up was 66 wk (range 36-138 wk). The change was statistically significant (p <0.05) for external rotation strength, Single Assessment Numeric Evaluation, and VAS reduction. Post-operatively, all patients returned to full duty at a median of 20 wk (range 12-36 wk).nnnConclusionnThe use of biceps tenodesis in conjunction with indirect, intra-articular arthroscopic paralabral cyst decompression is an effective technique in an active patient population with superior labral from anterior to posterior tear with associated paralabral cyst.

Glenoid neck Hounsfield units on computed tomography can accurately identify patients with low bone mineral density

BACKGROUNDnOsteoporosis is a costly and morbid disease with the first presentation often with a fragility fracture. The purpose of this study was to assess whether Hounsfield unit (HU) measurements on shoulder computed tomography could identify patients at risk of osteoporosis and aid in its diagnosis.nnnMETHODSnWe identified patients who had both a computed tomography scan of the glenoid and a dual-energy x-ray absorptiometry scan. Dual-energy x-ray absorptiometry results and HU measurements of the patients glenoid were recorded. Differences in HU measurements between patients with normal and abnormal central bone mineral density (BMD) were assessed. Correlations were calculated, and receiver operating characteristics were examined.nnnRESULTSnA total of 51 glenoids met the criteria. The mean glenoid HU measurement was 140.6 (95% confidence interval [CI], 120.1-161.1) in the osteoporotic group, 168.1 (95% CI, 152.7-183.5) in the osteopenic group, and 233.2 (95% CI, 210.1-256.4) in the normal BMD group (Pu2009<u2009.001). There was a significant correlation between mean glenoid HU measurement and patients t scores in the femoral neck (ru2009=u20090.581), total hip (ru2009=u20090.524), and lumbar spine (ru2009=u20090.345). The area under the receiver operating characteristic curve was 0.918. With 197 HUs used as the cutoff for diagnosis of abnormal BMD, the positive predictive value was 96.6%. With 257.1 HUs used as the cutoff, the negative predictive value was 100%.nnnCONCLUSIONnA patient with an HU measurement below 197 has a 97% chance of having low BMD, and a patient with a measurement over 257 likely has normal BMD. In patients with measurements between these values, a definitive diagnosis should be aggressively pursued. Opportunistic screening for a modifiable disease that has significant morbidity and mortality rates at no additional cost, radiation, or time is of great value.

Primary Circumferential Acetabular Labral Reconstruction: Achieving Outcomes Similar to Primary Labral Repair Despite More Challenging Patient Characteristics:

Background: Treatment of acetabular labral tears with moderate or severe intrasubstance damage or segmental defects remains a substantial challenge. Circumferential labral reconstruction with iliotibial band allograft is a relatively new technique that has been proposed to restore stability and eliminate high-stress junction points. Purpose: To compare outcomes between hips treated with primary allograft circumferential labral reconstruction and primary labral repair. Study Design: Cohort study; Level of evidence, 3. Methods: All consecutive hips between 2014 and 2015 that underwent primary reconstruction or primary repair by the senior surgeon were included and compared. Hips that had a prior intra-articular procedure were excluded. Patient-reported outcome (PRO) scores and visual analog scales were completed by patients within 1 week before surgery and between 22 and 26 months postoperatively. PROs included the modified Harris Hip Score, the International Hip Outcome Tool, and the 12-Item Short Form Health Survey for physical health. Pain and satisfaction were assessed with visual analog scales. Crude and inverse probability of treatment weighting comparisons of PROs between groups were performed. Results: A total of 162 hips met the inclusion criteria for this study, including 99 labral repairs and 63 complete labral reconstructions. Patients who underwent labral reconstruction were, on average, older (43.4 vs 29.5 years; P < .01), had a slightly higher body mass index (24.6 vs 23.0; P < .01), had hips with a higher Tönnis grade (grade 1 or 2: 25% vs 9%; P < .01), had higher preoperative pain scores (49.9 vs 41.5; P = .01), and had hips with more severe pathology (68% vs 5%; P < .01) as compared with patients with labral repair hips. Five (5%) labral repair hips and 5 (8%) labral reconstruction hips failed treatment (P = .48). Among hips that did not fail (n = 94 repairs, n = 58 reconstructions), all demonstrated statistically significant improvements in PROs, and there was no statistical difference in PROs between groups after weighting (P > .05). Conclusion: Primary circumferential labral reconstruction is a viable treatment option with promising short-term outcomes for hips that demonstrate moderate or severe labral damage. Despite less favorable preoperative characteristics, labral reconstruction offers similar outcomes when compared with labral repair in hips with less severe pathology.

Outcomes of Medializing Tibial Tubercle Osteotomy With Medial Reefing and Vastus Medialis Obliquus Advancement Coupled With Lateral Retinacular Z-Lengthening for Recurrent Patellar Instability

PURPOSEnPatella-femoral dislocations, although rare, can result in functionally limiting symptoms and limited return to prior activity levels. The purpose of this study is to report outcomes of a three-in-one patellar realignment surgery for treatment of recurrent patellar instability in a young, active duty military population.nnnMETHODSnWe conducted a retrospective chart review of all patients who underwent our senior authors three-in-one patellar realignment surgery for recurrent patellar instability in the setting of underlying anatomic malalignment. Our primary outcome measure was the rate of recurrent instability. Secondary outcome measures included rate of return to full unrestricted active duty military service and the functional outcome scores.nnnRESULTSnA total of 13 patients with an average follow-up of 16 months were included in this study. During the follow-up period, there were no reported instability events (either dislocation or subluxation). Three (23%) patients were separated secondary to issues with their operative knee and two additional patients were no longer on active duty at time of final follow-up. Six patients had paired (pre- and postoperative) Single Assessment Numerical Evaluation scores which showed a statistically significant improvement (p < 0.05) between the median pre- and postoperative Single Assessment Numerical Evaluation scores of 45 and 85, respectively.nnnCONCLUSIONnOur study demonstrates that the described patellar realignment procedure is effective at substantially reducing and possibly eliminating the symptoms of recurrent instability and allows a modest return to unrestricted active duty.

Low Incidence of Bone Health Presentations at National Hand Meetings

PURPOSEnThe purpose of this study was to determine the frequency with which osteoporosis topics (screening, medical treatment, and fracture prevention) are presented at national hand surgery meetings. This was compared with the frequency of the same topics presented at the Orthopaedic Trauma Association (OTA) annual meetings.nnnMETHODSnThe annual meeting programs for the American Society for Surgery of the Hand (ASSH), the American Association for Hand Surgery (AAHS), and the OTA from the previous 10 years (2007-2016) were searched for presentations that covered bone health at each of these meetings. We categorized the presentations as either instructional or research.nnnRESULTSnThere were 2 bone health instructional presentations at hand surgery meetings in contrast to 13 presentations at OTA meetings over the last 10 years. For the last 9 years, the OTA has featured at least 1 instructional presentation on bone health every year. We identified 11 research presentations at the hand surgery meetings compared with 16 at the OTA meetings.nnnCONCLUSIONSnOsteoporosis and bone health are infrequently presented instructional topics at national hand meetings compared with OTA meetings. The cause of the difference is unclear and likely multifactorial, varying each year with different program chairs and committees. The level of involvement of hand surgeons in osteoporosis management is controversial; however, incorporation of this topic may stimulate discussion and help identify solutions for this controversy.nnnCLINICAL RELEVANCEnIt may benefit hand surgeons to place more importance on osteoporosis screening and treatment. We believe that there should be an annual instructional course on this topic at the ASSH and AAHS meetings.